Israel Medical Association Journal

Background: Percutaneous dilatational tracheostomy (PDT) has become a standard technique for critically ill patients who require long-term ventilation. The most common early post-operative complication is bleeding related to anatomical variation in vasculature. The procedure is performed at the patient's bedside unless this is deemed unsafe and then the accepted alternative is open tracheostomy in the operating room. 

Objectives: To evaluate the use of pre-procedural ultrasound to aid in the decision of whether PDT in critical care patients should be performed at the patient's bedside or by open surgical tracheostomy.

Methods: Patients were jointly evaluated by a critical care physician and a head and neck surgeon. Based on this evaluation, the method of tracheostomy was determined. Subsequently, pre-procedural ultrasound examination of the anterior neck was performed. The final decision whether to perform PDT or open surgical tracheostomy was based on the ultrasound findings. Changes in management decisions following ultrasound were recorded. 

Results: We included 36 patients in this prospective study. Following ultrasound examination, the management decision was changed in nine patients (25%).

Conclusions: Pre-procedural ultrasound for critically ill patients undergoing tracheostomy can influence management decisions regarding the performance of tracheostomy. 

 

The unique characteristics of the next generation of medical professionals in Israel and the current model of physician employment in the country may pose a real threat to the high quality of both public clinical care and medical education in the near future, and to the continued flourishing of clinical research. According to the Israel Medical Association’s general obligations for Israeli physicians, the doctor should place the patient's interests foremost in his or her mind, before any other issue. This has led many to believe that selflessness or altruism should be among a physician’s core values. Is the application and realization of these obligations compatible with the realities of 21st century medicine? Is altruism still a legitimate part of the modern medical world? The Y generation, those born in the 1980s and 1990s, now comprise the majority of the population of residents and young specialists. They have been characterized as ambitious, self-focused, entrepreneurial, lacking loyalty to their employer, and seeking immediate gratification. Under these circumstances, is it possible to encourage or even teach altruism in medical school? Demands on physicians' time are increasing. The shortage of doctors, the growth of the population, the way in which health care is consumed, and the increasing administrative burden have all gnawed away at the time available for individual patient care. This time needs to be protected. The altruism of physicians could become the guarantee of first-rate care in the public sector. The continued existence of clinical research and high level clinical teaching also depends on the allocation of protected time. In light of the emerging generation gap and the expected dominance of Y generation physicians in the medical workforce in the near future, for whom altruism may not be such an obvious value, solutions to these predicaments are discussed.

Background: Seasickness is thought to result from conflicting inputs from the vestibular, visual and somatosensory systems. The otolithic organs, which are responsible for the sensation of linear acceleration and tilt, are important in the pathogenesis of seasickness. Vestibular evoked myogenic potentials test is an objective evaluation of saccular function.

Objective: To examine whether saccular function is related to the pathogenesis of seasickness.

Methods: VEMP1 was performed in 10 subjects susceptible to seasickness and in 14 non-susceptible subjects.

Results: Bilateral VEMP responses were obtained in 7 (50%) of the non-susceptible subjects and 1 (10%) of the susceptible subjects. No differences were found between the groups in P13 and N23 wave latencies, amplitudes, N13-P23 inter-peak latencies, and peak-to-peak asymmetry ratios. More subjects in the susceptible group had asymmetry ratios > 35%.   

Conclusions: The attenuated saccular response might be explained in the context of the neural-mismatch theory and/or the subjective vertical theory, as reflecting an adaptation effort to sea conditions. A larger study is necessary to determine whether a statistically significant difference in VEMP responses exists between seasickness-susceptible and non-susceptible subjects.
 

Background: Surgery for the closure of nasal septal perforation is challenging. Numerous techniques have been described.

Objectives: To assess whether nasal septal perforations heal more consistently if a connective tissue scaffold is placed between the repaired septal flaps.

Methods: We performed closure of a septal perforation via a closed approach using oral mucosal flaps without the interposition of a connective tissue graft in seven patients.

Results: Complete perforation closure was achieved in 5 cases (83.3%). There was no significant donor site morbidity.

Conclusions: These initial results suggest that this is an effective technique for closing nasal septal perforations; it obviates the morbidity of the open approach and the added operating time and morbidity associated with the harvesting of a connective tissue graft.